Mt. Hood Disability Services: Student Accommodation Request Form

STUDENT NAME:

STUDENT ID NUMBER:

DATE:

TERM:

Fall

Winter

Spring

Summer

YEAR:

* I WANT THE SAME ACCOMMODATIONS I HAD LAST TERM*

If you need to add additional accommodations, please schedule an appointment with the Coordinator of Disability Services by calling 503-491-6923.

Student Signature

TO BE COMPLETED BY DSO STAFF

Instructor Notification Form Completed			Date:
				DSO Staff Signature